Program Contact

Ruth Clinard
Child Mortality Review Consultant
Minnesota Department of Human Services
444 Lafayette Road North
PO Box 64943
St. Paul, MN 55155-0943
Phone: 651-431-4696
Fax: 651-431-7522

Program Description

Minnesota’s Child Mortality Review Program was established in 1989 by legislation. The program is federally funded by the Child Abuse Prevention and Treatment Act and state funds. In 2015, the Minnesota Legislature enacted a new statute that requires the Department of Human Services to lead an on-site review of all fatalities and near fatalities caused by maltreatment, and those that occur in licensed facilities and are not due to natural causes. The Minnesota Department of Human Services, Child Safety and Permanency Division has authority to conduct child death and near death reviews under state statute. Four state employees staff the program.


Minnesota has both state and local teams.

Systemic Critical Incident Review Process led by the Department (Kelly Knutson – Quality Assurance Supervisor)

The Department has been working with Collaborative Safety, LLC, an organization out of Tennessee, to implement a trauma-informed, robust and scientific systemic critical incident review process for child fatalities and near fatalities that are due to maltreatment or that occur in licensed facilities and were not due to natural causes. The review process utilizes components from the same science used by other safety critical industries, including aviation and health care. The approach moves away from blame and toward a system of accountability that focuses on identifying underlying systemic issues to improve complex social systems such as Child Welfare.
This review process takes a systemic approach that departs from surface level understandings of how systems fail and seeks out the complex interplay of systemic factors. Collaborative Safety supports agencies/systems to develop a proactive response to critical incidents and a responsive system dedicated to learning. The Collaborative Safety Model currently being implemented, engages local and state agency leadership, frontline staff, and other key child welfare stakeholders on safety science principles, supporting safety advancement and system change.

Collaborative Safety’s founders Dr. Scott Modell and Noel Hengelbrok were referred to as pioneers in applying safety science to the field of child welfare by the Federal Commission to Eliminate Child Abuse and Neglect Fatalities. The Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF) was established by the Protect Our Kids Act of 2012, which garnered broad, bipartisan support in the House, passed the Senate unanimously, and was signed by President Barack Obama on January 14, 2013. Its mission was to develop a national strategy and recommendations for reducing fatalities across the country resulting from child abuse and neglect. Both Modell and Hengelbrok were asked to present to the commission on Tennessee’s Child Death Review Process and how Safety Science has been successfully applied. Based on their input, the Commission developed the following Recommendation: “Fund pilot programs to test the effectiveness of applying principles of safety science to improve CPS practice” (CECANF, 2016, p.78).

State Panel: (Ruth Clinard – Child Mortality Review Consultant)

The Minnesota Child Mortality Review Panel is comprised of 30 members and meets 6 times a year. The Child Mortality Review Panel examines up to eight cases at each meeting. The Panel makes recommendations to improve the state and local systems that protect children.

SUID/SDY Subcommittee: (Chairperson – Gloria Mutombo, SUID epidemiologist at Minnesota Department of Health)

The Sudden Unexplained Infant Death and Sudden Death in the Young Subcommittee of the State Panel reviews all sudden unexplained infant deaths and sudden death in the young cases. The subcommittee examines the services provided to the family, and develops recommendations to prevent future deaths.

Local Teams: (Chairperson – county or tribal child protection supervisor)
There are 89 Local Child Mortality Review Teams including two American Indian tribal teams. The local review team conducts a comprehensive review of the facts of the case and makes recommendations to improve local practice and collaboration of the local agencies. Recommendations are also made for changes to state policies and laws.


The purpose of the Minnesota Child Mortality Review process is to make recommendations to improve outcomes for all children and families within the child welfare system and prevent future child fatalities and near fatalities.
The Child Mortality Review Panel collaborates with the Minnesota Department of Health to study Sudden Unexplained Infant Deaths and Sudden Deaths in the Young to learn from the cases ways that may help to prevent future deaths.


Standardized data reporting forms are completed for all state reviews. Data from state reviews is entered into the National Center for Child Death Review Case Reporting System.

Prevention Initiatives

The Minnesota Child Mortality Review Panel has partnered with the Minnesota Department of Health to promote infant and child safety messages. Local reviews have resulted in changes to local policy or practice including better collaboration between child welfare partners and local agencies.


Minnesota Child Mortality Review has authority to conduct reviews through Minnesota Statutes section 256.01, subdivision 12. The Minnesota Child Fatality/near Fatality On-site Review process is authorized in Minnesota Statutes section 256.01, Subd. 12a. Additional guidelines for mortality reviews are described in the Minnesota Administrative Rule 9560.0232, Subpart 5.


Training aimed at child protection staff responsible for conducting reviews of child fatalities and near fatalities is provided to local agency staff and panel members on a periodic basis (training was provided in July 2016). Technical assistance is provided to counties regarding local reviews whenever needed.

Highly specialized training for conducting the systematic critical incident review process was provided for Department staff and fifteen county and tribal child welfare supervisors in 2017.

Last Updated: March 2018